‘This is important’: Mammograms significantly improve survival beyond 80 years of age

By: Josh Friedman

From: healio.com

Key takeaways:

• Women diagnosed with breast cancer at 80 years and older had significantly improved survival if they had recent mammograms.
• Mammograms discovered smaller tumors at less advanced stages.

Older age should not stop women from getting mammograms.

A retrospective analysis found women with breast cancer aged at least 80 years had a 55% lower risk for recurrence and more than 70% lower risk for death if they were screened within 2 years of diagnosis.

“This is important. People need to get screened if they’re healthy and want to stay healthy,” Nimmi Kapoor, MD, breast surgical oncologist and associate professor of surgery at David Geffen School of Medicine at UCLA, told Healio.

“Screening mammogram is an easy thing to do, and we can easily offer that.”

Is screening necessary?

The number of adults living in the U.S. aged 65 years and older increased by 15.5 million between 2010 and 2020, according to study background.

Previous studies have shown age to be a risk factor for breast cancer, but the United States Preventative Services Task Force does not currently have screening recommendations for women aged older than 75 years.

Conversely, American Cancer Society recommends to continue screening if a patient has good health and is expected to live at least 10 years.

Some clinicians wonder if screening adds value to this patient population.

“We’ve been seeing more and more de-escalation of care in elderly women so we can do things like not remove lymph nodes and not offer radiation when we find cancer that is really small, less aggressive and less likely to lead to severe long-term problems,” Kapoor said.

“That led us to thinking, do we even need to find these cancers?”

Kapoor and colleagues investigated using a cohort of 174 individuals (99% women; 70% white) aged at least 80 years (median, 83 years; interquartile range, 81-87) who were diagnosed with breast cancer at UCLA between 2013 and 2020.

The group included 98 patients who received mammograms within 2 years of diagnosis and 76 who did not.

Outcome differences based on screening served as the primary endpoint.

Mammograms prevent unnecessary deaths

At median follow-up of 55 months, patients who received mammograms had significantly improved DFS (HR = 0.45; 95% CI, 0.3-0.67) and OS (HR = 0.26; 95% CI, 0.13-0.54).

Survival benefits of screening remained after adjusting for age, surgery and tumor subtype.

“I didn’t think we would see a survival difference,” Kapoor said. “I thought, these are elderly patients, they’re likely going to die of other causes, and there’s probably going to be similar rates of death between the two groups.”

Patients who received mammograms had a lower median age at diagnosis (83 years vs. 85 years; P = .001) and lower rate of symptomatic tumors (34% vs. 88%; P < .001).

Those who were screened had a higher likelihood of having ductal carcinoma in situ, whereas those who were not had a greater likelihood of having invasive ductal carcinoma (P = .037).

Tumors of patients who did not receive mammograms tended to be larger (median, 3.1 cm vs. 1.7 cm; P < .001), higher grade (P < .001) and more advanced (P < .001).

Individuals who were screened had a higher likelihood of undergoing breast-conserving surgery (82.4% vs. 60.6%; P < .001) and radiation (43% vs. 20%; P = .003), and those who did not have a mammogram had a higher likelihood of undergoing mastectomy or not having any surgery (38.8% vs. 17.6%; P = .009).

Researchers acknowledged study limitations, including its retrospective nature and the small cohort.

“We have an aging population, which is good, but we still have an aging population that is prone to getting breast cancer,” Kapoor said. “We need to think about how healthy our aging population is so we can avoid letting them die unnecessarily from a cancer that could have been caught with technology we already have.”

Age ‘doesn’t stop’ cancer

This topic hits Kapoor close to home.

“My own grandmother died of breast cancer [at 82 years old], and when her breast cancer was found [at 80], she was already stage 4,” she said. “At the time, she was living in Canada where they stopped mammograms routinely for women at age 70 and beyond.”

Kapoor noted concerns of overdiagnosis among older individuals, and future research should prospectively evaluate whether screening leads to more unnecessary callbacks or biopsies.

However, she also emphasized diagnosis for this group tends to be clearer.

“Women in the elderly populations should have, ideally, previous mammograms for comparison, that’s one benefit,” Kapoor said. “Number two, mammography sensitivity and specificity is improved because of the decreased density of the elderly breast tissue. Also, elderly women shouldn’t have a lot of changes on mammogram over time. A change in a postmenopausal woman on mammogram is often a clue to something’s wrong, and often, indeed, something is wrong, so you don’t get a false alert. You actually get an early cancer pickup.”

Some women over the age of 80 may not be able to move toward the mammogram machine to get screened, but breast exams could be “useful” for this population.

“We don’t have enough data to support breast exam, which is why guidelines dropped that off the radar, but primary care and other providers can easily palpate breasts,” Kapoor said. “We don’t do that as much as we need to in this elderly population.”

Early breast cancer diagnoses could lead to less invasive treatments, such as cryoablation, minimal surgery or endocrine therapy alone, though those still need investigation, too.

“Cancer doesn’t stop at a certain age,” Kapoor said. “It keeps coming, and with age, there’s an increase in cancer risk. We need to think about ordering those screening modalities, like mammography, especially for our women, because it is an easy test. It’s one of the least invasive tests we have for detecting breast cancer and finding early-stage cancer. All our newer abilities to downstage and de-escalate care come only because we find cancer early. If we find cancer when it’s too advanced, we can’t utilize all our newer methods of de-escalating care.

“Had my grandmother maybe had a breast exam or a mammogram 5 years before my aunt found a large mass in her breast, which led to the diagnosis of stage 4 breast cancer, I can’t help but think, perhaps, that death from breast cancer for my grandmother could have been avoided, or delayed.”